- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.43 / $1,228.44 / $2,256.27
| Professional | | $668.43 | $1,228.44 | $2,256.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.01 / $1,844.64 / $5,023.00
| Facility | | $1,031.01 | $1,844.64 | $5,023.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,464.00 / $1,844.64 / $2,364.42
| Facility | | $1,464.00 | $1,844.64 | $2,364.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $5,023.00 / $7,305.00
| Facility | | $3,044.00 | $5,023.00 | $7,305.00 |